In the JournalsPerspective

Expert opinions on measles-specific vaccine exemptions vary widely

While conventional approaches to mandating vaccine compliance have focused on broadly eliminating all nonmedical vaccine exemptions for school children, a recent commentary in Pediatrics proposes that public health policy may be better served by only eliminating nonmedical exemptions for measles vaccination — a position denounced by other experts.

“Efforts to restrict parents’ ability to exempt children from receiving vaccinations required for school entry have recently reached a pinnacle,” Douglas J. Opel, MD, MPH, of the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Research Institute, and colleagues wrote. “Although laudable in their objective, policies eliminating nonmedical exemptions from all vaccines are scientifically and ethically problematic. In the present article, we argue for an exemption policy that eliminates nonmedical exemptions just for the measles vaccine and is pursued only after other less restrictive approaches have been implemented and deemed unsuccessful.”

Doug Opel

Douglas J. Opel

In a related editorial, Kathryn M. Edwards, MD, FAAP, professor of pediatrics at Vanderbilt University and an Infectious Diseases in Children Editorial Board member, and colleagues wrote that this approach is incorrect and has the potential to do more harm than good.

“[Opel and colleagues’] primary premise is that recent attempts to restrict nonmedical vaccine exemptions are scientifically and ethically problematic,” Edwards and colleagues wrote. “However, we disagree with their interpretations and seek to provide an alternative approach.”

The goal to protect as many children as possible from deadly vaccine-preventable diseases is at the core of both arguments; however, Opel and colleagues suggest that less restrictive policies may work to appease vaccine-refusing parents. The researchers singled out measles for a number of reasons, including its contagiousness.

“Measles virus is extraordinarily contagious,” Opel and colleagues wrote. “Its basic reproduction [R0] number is 12 to 18. Only one other vaccine-preventable infectious agent is as contagious (Bordetella pertussis); all others have a basic reproduction number that ranges from 4 to 7.”

Edwards and colleagues countered that the R0 value of an infectious disease is an unreliable indicator of the threat it poses to public health.

“The fact that some vaccine preventable infections have R0 values lower than 12 to 18 should not be reassuring,” Edwards and colleagues wrote. “In fact, the 1918 A/H1N1 influenza strain, which led to a pandemic resulting in the deaths of 20 to 40 million worldwide, had an R0 of 2 to 3 and more recently, the Ebola outbreak in Western Africa, which also had worldwide impact, had an R0 of only 1.5.”

Opel and colleagues also stated that the public health threat posed by measles, coupled with the safety and efficacy of measles vaccine, positions it as the most unique of all vaccine-preventable diseases.

“Measles disease is severe enough, outbreaks common enough and containment costly enough to be a significant threat to public health,” Opel and colleagues wrote. “Measles vaccine is safe and effective at preventing an outbreak. Adverse outcomes from measles vaccine are extremely rare, and when administered in two appropriately spaced doses, measles vaccine induces durable immunity.”

However, the public health threat posed by measles and the reliability of its vaccine are not characteristics exclusive to measles, according to Edwards and colleagues.

“Far from being unique to measles, the threat to public health and the safety of available vaccines are factors that characterize all vaccine-preventable infections,” Edwards and colleagues wrote.

Opel and colleagues argue further that total elimination of nonmedical exemptions presents an ethical dilemma for physicians, who are bound to the ethical principle of the least restrictive alternative.

“Perhaps the most persuasive argument against invoking a sweeping policy that eliminates nonmedical exemptions from all vaccines is that it violates the ethical principle of least restriction,” Opel and colleagues wrote. “Focused policy that eliminates nonmedical exemptions just from measles vaccine is simply one alternative to eliminating nonmedical exemptions from all vaccines; other effective options include increasing the effort required to claim a nonmedical exemption and enforcing current vaccine requirements.”

Edwards and colleagues assert that the invocation of the least restrictive alternative is not applicable to the question of mandatory vaccination.

“The least restrictive alternative doctrine … was developed by the courts to address serious deprivations of personal liberty, such as involuntary commitment and quarantine and so is not generalizable to all public health activities,” Edwards and colleagues wrote. “Ethics is not the only issue here. As a matter of law, the government is free to require immunizations, reflecting its power, and its duty, to protect the health of the public.”

Edwards and colleagues further argue that the proposal forwarded by Opel and colleagues could have unintended consequences to public health by creating a misconception that measles vaccine is more important than other required vaccinations. Moreover, because measles vaccine is currently only available as a covalent vaccine with mumps and rubella, singling out measles could create demand for a nonexistent monovalent vaccine — potentially causing further parental confusion and frustration.

“If nonmedical exemptions are eliminated for measles vaccine but not for other vaccines, an artificial demand for monovalent vaccine products, which are currently not manufactured, could be created,” Edwards and colleagues wrote.

Kathryn Edwards

Kathryn M. Edwards

Opel and colleagues concluded by stating that exclusively eliminating nonmedical exemptions for measles vaccination will ultimately ensure that more children are protected from harm.

“Our goal is simple: to see as many children immunized as possible,” Opel and colleagues wrote. “We believe a policy to eliminate nonmedical exemptions s from measles vaccine alone is more justifiable, sustainable, and enforceable than eliminating nonmedical exemptions s from all vaccines and therefore more likely to achieve this goal.”

Edwards and colleagues maintained that their position to broadly eliminate nonmedical vaccine exemptions is supported by the scientific community at large.

“We believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines, a position shared by the American Medical Association, the Infectious Diseases Society of America and is currently the basis of a policy statement being developed by the American Academy of Pediatrics,” Edwards and colleagues concluded. – by David Costill

Disclosures: Opel and Edwards report no relevant financial disclosures. Please see the full studies for a list of all other authors’ relevant financial disclosures.

While conventional approaches to mandating vaccine compliance have focused on broadly eliminating all nonmedical vaccine exemptions for school children, a recent commentary in Pediatrics proposes that public health policy may be better served by only eliminating nonmedical exemptions for measles vaccination — a position denounced by other experts.

“Efforts to restrict parents’ ability to exempt children from receiving vaccinations required for school entry have recently reached a pinnacle,” Douglas J. Opel, MD, MPH, of the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Research Institute, and colleagues wrote. “Although laudable in their objective, policies eliminating nonmedical exemptions from all vaccines are scientifically and ethically problematic. In the present article, we argue for an exemption policy that eliminates nonmedical exemptions just for the measles vaccine and is pursued only after other less restrictive approaches have been implemented and deemed unsuccessful.”

Doug Opel

Douglas J. Opel

In a related editorial, Kathryn M. Edwards, MD, FAAP, professor of pediatrics at Vanderbilt University and an Infectious Diseases in Children Editorial Board member, and colleagues wrote that this approach is incorrect and has the potential to do more harm than good.

“[Opel and colleagues’] primary premise is that recent attempts to restrict nonmedical vaccine exemptions are scientifically and ethically problematic,” Edwards and colleagues wrote. “However, we disagree with their interpretations and seek to provide an alternative approach.”

The goal to protect as many children as possible from deadly vaccine-preventable diseases is at the core of both arguments; however, Opel and colleagues suggest that less restrictive policies may work to appease vaccine-refusing parents. The researchers singled out measles for a number of reasons, including its contagiousness.

“Measles virus is extraordinarily contagious,” Opel and colleagues wrote. “Its basic reproduction [R0] number is 12 to 18. Only one other vaccine-preventable infectious agent is as contagious (Bordetella pertussis); all others have a basic reproduction number that ranges from 4 to 7.”

Edwards and colleagues countered that the R0 value of an infectious disease is an unreliable indicator of the threat it poses to public health.

“The fact that some vaccine preventable infections have R0 values lower than 12 to 18 should not be reassuring,” Edwards and colleagues wrote. “In fact, the 1918 A/H1N1 influenza strain, which led to a pandemic resulting in the deaths of 20 to 40 million worldwide, had an R0 of 2 to 3 and more recently, the Ebola outbreak in Western Africa, which also had worldwide impact, had an R0 of only 1.5.”

Opel and colleagues also stated that the public health threat posed by measles, coupled with the safety and efficacy of measles vaccine, positions it as the most unique of all vaccine-preventable diseases.

“Measles disease is severe enough, outbreaks common enough and containment costly enough to be a significant threat to public health,” Opel and colleagues wrote. “Measles vaccine is safe and effective at preventing an outbreak. Adverse outcomes from measles vaccine are extremely rare, and when administered in two appropriately spaced doses, measles vaccine induces durable immunity.”

However, the public health threat posed by measles and the reliability of its vaccine are not characteristics exclusive to measles, according to Edwards and colleagues.

“Far from being unique to measles, the threat to public health and the safety of available vaccines are factors that characterize all vaccine-preventable infections,” Edwards and colleagues wrote.

Opel and colleagues argue further that total elimination of nonmedical exemptions presents an ethical dilemma for physicians, who are bound to the ethical principle of the least restrictive alternative.

“Perhaps the most persuasive argument against invoking a sweeping policy that eliminates nonmedical exemptions from all vaccines is that it violates the ethical principle of least restriction,” Opel and colleagues wrote. “Focused policy that eliminates nonmedical exemptions just from measles vaccine is simply one alternative to eliminating nonmedical exemptions from all vaccines; other effective options include increasing the effort required to claim a nonmedical exemption and enforcing current vaccine requirements.”

Edwards and colleagues assert that the invocation of the least restrictive alternative is not applicable to the question of mandatory vaccination.

“The least restrictive alternative doctrine … was developed by the courts to address serious deprivations of personal liberty, such as involuntary commitment and quarantine and so is not generalizable to all public health activities,” Edwards and colleagues wrote. “Ethics is not the only issue here. As a matter of law, the government is free to require immunizations, reflecting its power, and its duty, to protect the health of the public.”

Edwards and colleagues further argue that the proposal forwarded by Opel and colleagues could have unintended consequences to public health by creating a misconception that measles vaccine is more important than other required vaccinations. Moreover, because measles vaccine is currently only available as a covalent vaccine with mumps and rubella, singling out measles could create demand for a nonexistent monovalent vaccine — potentially causing further parental confusion and frustration.

“If nonmedical exemptions are eliminated for measles vaccine but not for other vaccines, an artificial demand for monovalent vaccine products, which are currently not manufactured, could be created,” Edwards and colleagues wrote.

Kathryn Edwards

Kathryn M. Edwards

Opel and colleagues concluded by stating that exclusively eliminating nonmedical exemptions for measles vaccination will ultimately ensure that more children are protected from harm.

“Our goal is simple: to see as many children immunized as possible,” Opel and colleagues wrote. “We believe a policy to eliminate nonmedical exemptions s from measles vaccine alone is more justifiable, sustainable, and enforceable than eliminating nonmedical exemptions s from all vaccines and therefore more likely to achieve this goal.”

Edwards and colleagues maintained that their position to broadly eliminate nonmedical vaccine exemptions is supported by the scientific community at large.

“We believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines, a position shared by the American Medical Association, the Infectious Diseases Society of America and is currently the basis of a policy statement being developed by the American Academy of Pediatrics,” Edwards and colleagues concluded. – by David Costill

Disclosures: Opel and Edwards report no relevant financial disclosures. Please see the full studies for a list of all other authors’ relevant financial disclosures.

    Perspective
    Paul A. Offit

    Paul A. Offit

    Opel and colleagues argue for disallowing nonmedical exemptions for the measles vaccine, only. The targeted recommendation centers on what the authors believe are “moral claims such as liberty, privacy, opportunity, and justice.” Presumably, the moral claims they are referring to relate to a parent’s right to choose what is best for their child. And while it is true that state hearings on this issue typically sound the theme of parents’ rights, what is often lost in these deliberations is that children have rights, too — like the right to a long and healthy life: one free of the debilitating and sometimes fatal consequences of vaccine-preventable illnesses.

    When seeking a moral compass, Opel and colleagues could have more reasonably considered the “equal protection” clause of the 14th Amendment — specifically, that all citizens are entitled to equal protection under the law. In other words, just because some parents harbor ill-founded beliefs that vaccines cause autism, cancer, allergies, asthma, strokes, multiple sclerosis, ovarian failure, hyperactivity disorder, chronic fatigue syndrome, permanent brain damage and mad-cow disease does not mean that their children should be afforded less protection under the law. It is a civil rights issue. And even though children do not vote, public health officials and pediatricians should not further mute children’s voices by doing what is politically expedient instead of what is right.

    By arguing for the elimination of nonmedical exemptions — a strategy now embraced by the American Medical Association, the Infectious Diseases Society of America, and soon the American Academy of Pediatrics — professional societies are now finally taking a stand for children against the irresponsible acts of their parents.

    • Paul A. Offit, MD
    • Chief of the division of infectious diseases The Children’s Hospital of Philadelphia Infectious Diseases in Children Editorial Board member

    Disclosures: Offit reports no relevant financial disclosures.